Mental State Examination Terminology

Description:

The overlap between neurology and psychiatry should be obvious, given the two disciplines’ shared concerns with disorders of the human nervous system and the effect of these disorders on such fundamental aspects of our species as thoughts, beliefs, perceptions, and feelings. Nevertheless there is quite a division in terms of training, specialists (medical or otherwise), and service structures for patients who have disorders of the brain or mind. These structural and professional divisions can arguably lead to difficulties for patients accessing appropriate assessments and treatments. In the UK at least it is not currently a requirement of either neurological or psychiatric training to have experience of the other speciality, although progress is being made slowly in this respect with the introduction of more formal neuropsychiatry training modules into both neurology and psychiatry higher training schemes.

This issue of Neurology in Practice may go some way towards addressing this gap. Perusal of the literature will reveal that there have long been those arguing for bridges, rapprochements, and integration between the two disciplines, but real change is harder to see. There continues to be controversy within psychiatry whether the discipline is “mindless” or “brainless” and in which direction it and its practitioners should move.

The persistence of mind brain dualism is sadly all too common in our medical practice. It is not uncommon for patients with primary psychiatric illness to have minimal examination of physical state and the mental state examination is rarely done in a systematic way in general medical or even neurological settings. Of course, sometimes that is entirely appropriate, but just as psychiatrists should hopefully be able to detect and describe physical signs, so too should the neurologist be able to describe adequately and systematically abnormalities of mental state.

Studies have repeatedly shown that psychiatric illness in medical patients very often remains unrecognised. While this may have important implications for the treatment of patients, there is evidence that detection may be increased both by increasing the length of time available for assessments and by improving the assessment skills themselves. Communication styles which facilitate the detection of psychiatric morbidity or co-morbidity include listening, open ended questioning, developing an empathic rapport, interviewing patients in private, and using verbal and non-verbal behaviours to encourage disclosure (not, for example, asking questions while writing notes or interviewing people in bed surrounded by trainees or students).

THE MENTAL STATE

It is usual when describing mental states to divide the examination into the following headings: appearance and behaviour, orientation, attention and concentration, memory, mood, speech and language, perceptions and thoughts and insight (box 1).

This article aims to review the basic components of the mental state examination and give a structure for recording it. Problems of terminology or diagnosis that are likely to confront neurologists are discussed.

Appearance and behaviour

Initial examination of the patient will allow the examiner to comment on various aspects of appearance and behaviour. This includes the general level of motor activity, apparent distractibility, self care, appropriateness of dress (any evidence of disinhibition?), cooperativeness, and hostility. The manner of initial contact may be observed: eye contact, hand shaking, and posture. Of course, like many signs on examination, these have limited diagnostic significance in isolation but need to be part of an integrated mental state examination. Understandably, in busy wards with junior staff changing shifts, detailed behavioural observations may be difficult. When this is the case it may be helpful to use observational charts—for example, sleep charts, activity records, dietary records. These are simple diary style records usually divided into manageable slots, hourly or less frequently to record patient behaviours.

A particularly common clinical scenario deserves special mention. Delirium—synonyms for which include acute confusional state, acute organic brain syndrome, acute organic reaction, and acute psycho-organic syndrome—commonly causes a fluctuating clinical picture which can lead to different observations and opinions in different members of the clinical team. These inconsistencies may even be mistakenly attributed to feigning or “functional overlay”. The active delirious patient, who is restless, agitated, and hyperresponsive to stimuli, is rarely missed as he causes considerable management problems. The hypoactive delirious patient, though more common, is more likely to be missed as he is undemanding, sleepy, and quiet.

Box 1: Components of the mental state

  • Appearance and behaviour
  • Orientation
  • Attention and concentration
  • Memory
  • Mood and affect
  • Speech and language
  • Perceptions
  • Thought content
  • Insight

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